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APGAR score post-birth including scores at 1, 5 and 10 minutes.

LOINC codes exist for each of the proposed data elements: 11884-4 - Gestational age Estimated 73766-8 - Place where birth occurred [US Standard Certificate of Live Birth] 64710-7 - Was your pregnancy a live birth, stillbirth, miscarriage, abortion, or ectopic pregnancy [PhenX] 8339-4 - Birth weight Measured 8305-5 - Body height --post partum 9272-6 - 1 minute Apgar Score 9274-2 - 5 minute Apgar Score 9271-8 - 10 minute Apgar Score

The number of fetal deaths in this delivery.

LOINC codes exist for each of the proposed data elements: 69461-2 - Mother's body weight --at delivery 68493-6 - Prenatal visits for this pregnancy # 69044-6 - Date first prenatal visit 57722-1 - Birth plurality of Pregnancy 73772-6 - Number of fetal deaths delivered 73773-4 - Number of infants in this delivery delivered alive

This data element carries information on Self-care that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Self-care is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as eating, caring for teeth, putting clothes on, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Self-care concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Self-care data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as eating, oral hygiene, upper body dressing using assessments coded with LOINC.

LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966

This data element carries information on Mobility that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Mobility is a broad domain. Using the conceptual framework of the International Classification of Function (ICF), it includes aspects such as rolling over, transferring, walking short distances, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Mobility concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Mobility data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as roll left and right, car transfer, walk 10 feet using assessments coded with LOINC.

LOINC. LOINC is a freely available global standard that contains a well-developed model for representing variables, answer lists, and the collections that contain them.* Many clinical assessments, scales, and other observations related to functioning are present in LOINC, including all of the variables on the PAC assessments for SNFs, IRFs, LTCHs, and HHAs. Regenstrief operates a robust process for adding new content (including functioning assessment instruments) if key gaps are identified. *PMID: 22899966

The date when the prescription was initially written or authored.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

A specific date/time or interval of time during which the administration took place (or did not take place, when the 'notGiven' attribute is true).

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

Patient income level

Identifies the change (or lack of change) at the point when the status of the goal is assessed

HL7 FHIR

Medically necessary equipment (and the corresponding order) that a physician prescribes for use in a patient’s home, including wheelchairs, walkers, and hospital beds.

The Centers for Medicare & Medicaid Services (CMS) annually updates a spreadsheet that contains a list of the HCPCS codes for DME MAC and Part B MAC jurisdictions to reflect codes that are either added or discontinued (deleted) each year. The jurisdiction list is an Excel file and is available at https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center

Reference to a condition that is the reason for the medication administration.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

The units of measure associated with the amount of medication given at one administration event

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

The amount of the medication given at one administration event.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

A code (or set of codes) that specify the medication that was administered.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

The age of the individual when they stopped nicotine consumption/use. Question Prompt: Age stopped nicotine consumption/use.

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.

Indicates the amount of medication per dose that is to be used by the patient.

Date Medication Prescribed and Date Medication Administered: dateTime Data Type (FHIR): http://hl7.org/fhir/datatypes.html#dateTime Medication Prescribed Code and Medication Administered Code: RxNorm: https://www.nlm.nih.gov/research/umls/rxnorm/index.html Medication Prescribed Dose Units and Medication Administration Dose Units: UCUM: http://unitsofmeasure.org

The date the individual when they stopped nicotine consumption/use. Business rule: If quit date is within the last 30 days there should be a full date. If not, partial dates are accepted, or if null look for Quit Age

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.

The patient’s pack-years of smoking, or the information needed to determine the pack-years (e.g., packs per day and years of smoking).

Unified Code for Untis of Measure (UCUM) units for pack years and packs per day. There is also a LOINC code for packs per day (8663-7) and years smoked (88029-4).

In the past year whether patient has been unable to afford or access medicine or or any health care (medical, dental, mental health, vision) services. (LOINC) LA30128-5 LA15832-1 (Very hard), 2; LA14745-6 (Hard), 3; LA22683-9 (Somewhat)" Synonyms: (SNOMEDCT) 423593006 Inadequate healthcare resources (ICD-10-CM) Z59.63 (Unable to pay for medical care) Z59.61 (Unable to pay for prescriptions)

LOINC 93031-3 In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?

The age of the individual when they started nicotine consumption/use. Question Prompt: Age started nicotine consumption/use.

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.

Tobacco/Nicotine containing products used as a method of consumption. Question Prompt: What type(s) of tobacco products? Permissible Values: o Cigarette (SNOMED: 66562002) A thin cylinder of ground or shredded tobacco that is wrapped in paper, lit, and smoked. o Cigar (SNOMED: 26663004) A tube of tobacco that is thicker than a cigarette, wrapped in tobacco leaf, lit, and smoked. Cigars include regular cigars, cigarillos, and little filtered cigars. o Pipe (SNOMED: 84498003) A tube with a small bowl at one end that is filled with tobacco, lit, and smoked. o Smokeless (SNOMED: TBD) This delivery mechanism does not require smoking and includes, Chewing tobacco, Dip, Snuff, Dissolvable and Snus. o E-Cigarette/Vape (SNOMED: TBD) An electronic cigarette is a vaporizer device that simulates smoking by providing some of the aspects of smoking that includes nicotine but without combusting tobacco. Also called E-Cigs, Personal Vaporizer. o Unknown-(SNOMED: TBD) An individual for whose tobacco product use is unknown.

There are SNOMED and LOINC Codes for most of the data elements but new codes will be requested for eCigarette use.